National infarct angioplasty project : review of cardiac ...

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NHS Heart Improvement Programme National Infarct Angioplasty Project – review of cardiac networks December 2007NIAP Cardiac Network Survey - September 2007The NHS Heart Improvement Programme received a request from theDepartment of Health to gain a snapshot of reperfusion activity in all of thecardiac networks to provide additional information to support the findings ofthe National Infarct Angioplasty Audit.Phase 1 was a survey (appendix A) of the 31 cardiac networks requestinginformation on the geographical coverage of the network; pre-hospitalthrombolysis services; arrangements for ambulance transfers; hospital basedreperfusion services; and future plans for changes to reperfusion services.All 31 networks responded.Phase 2 focussed on the 04 December meeting with cardiac networks todiscuss the findings of the survey and discuss in more detail the barriers tochange of implementing a PPCI service and learning and sharing experiencesfrom networks across the country.Phase one key findingsService provisionThis question is to gain a picture of where primary PCI is operational. It mustbe noted this may only be in one centre in a network.Of the 31 cardiac networks in England, 65% provide a pre-hospitalthrombolysis (PHT) service, whilst 13% of networks (those in London) do notprovide any PHT services due to close proximity to PPCI centres andambulance journey times being within target limits for the service.74% of networks offer PPCI in at least one centre, whilst 26% do not provideany PPCI services at all. Of the 31 networks, 61% offer a mixture of bothPHT and PPCI services to STEMI patients.This response does not include in-hospital thrombolysis.HIP NIAP Analysis report – V1 1

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• It must be noted that some networks are very close to providing a PPCI only service e.g., Greater Manchester and Cheshire (12) do not use PHT in Greater Manchester but there are a couple of areas in Cheshire. Ambulance Transfers Cardiac networks were asked to identify the breakdown of arrangements for transfer of STEMI patients to PPCI centres. For those networks that provide PPCI, including those that offer a mixture of PHT & PPCI, 43% of networks transfer all STEMI patients directly to a PPCI centre. For those networks that offer both a PPCI and PHT service, 16% of patients are accessed at a non-PPCI centre before being transferred to a PPCI centre. Transfer arrangements across network Type of PPCI service n Not transferred for Transferred from Transferred direct offered across network PPCI DGHs from scene Only PPCI 4 0 0% 2 50% 2 50% PPCI and PHT 19 8 42% 3 16% 8 42% Overall 23 8 35% 5 22% 10 43% All networks were asked to identify what proportion of ambulance crews have 12-lead ECG recording; have paramedics trained to interpret the ECG; and can use telelink of any kind. All ambulance crews in all networks use 12 lead ECG recording. For those networks only providing a PHT service, 89% of crews are trained to interpret the ECG, and 44% have full access to telelink facilities. For those networks only providing a PPCI service, 87% of crews are able to interpret the ECG and 30% have full access to telelink facilities. Some areas do not use telelink as they use the scoop and run system. Proportion of ambulance crews that have 12-lead ECG recording; have paramedics trained to interpret ECGs; and have telelink capabilities - By service category 100% 11% 13% 90% 16% 22% 26%Percentage of service category 80% 39% 70% 60% 33% 37% None 50% 100% 100% 100% Some 89% 87% 30% 84% All 40% 30% 44% 20% 37% 30% 10% 0% 12 lead ECG 12 lead ECG 12 lead ECG Paramedics Paramedics Paramedics Telelink Telelink Telelink interpret interpret interpret PHT . pPCI . Mixture Service category HIP NIAP Analysis report – V1 3

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Of those networks providing PHT, 63% use JRCALC defined criteria for itsuse; with 26% using other or local guidelines. 11% of respondents did notindicate what criteria they use.Hospital based reperfusion servicesFor their patch, networks were asked to identify what proportion of hospitalsprovide PPCI in at least one centre and state the arrangements for receivingSTEMI patients. 48% of networks transfer STEMI patients to PPCI centres;26% receive STEMI patients and do not provide PPCI; and 26% of networkshave PPCI centres that receive STEMI patients directly. Number / proportion of networks that provide PPCI in at least one hospital n = 31 networks 8 26% 15 48% 8 26% PPCI Not provided Only PCI centres Transfer to PCI Centres availableCombined: Per hospital and network perspectives: proportion of PPCI offered - only at PCI centres; transfer to PCI centre available; or PPCI not available at all 100% 90% 26% 80% 70% 64% 60% Proportion PPCI not provided 50% 48% Transfer to PCI Centres PCI centres only 40% 30% 21% 20% 26% 10% 15% 0% Hospitals NetworksNetwork level applies where at least one hospital fits the categoryHIP NIAP Analysis report – V1 4

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For those networks that have at least one centre providing PPCI, they wereasked to identify the different times that PPCI is offered to STEMI patients.13 networks offer a 24/7 PPCI service; 7 networks offer the service ‘in-hoursonly’; none of the 31 networks offer a PPCI service ‘in hours’ and atweekends. Five networks stated that they offer ‘other’ PPCI arrangements:-this includes provision of an ‘ad-hoc’ service (if the patient is in the right placeat the right time) and some 8am to 8pm PPCI services. Breakdown of times PPCI offered, at network and hospital level 20 19 18 16 14 13 13 Number of networks / sites 12 "twenty four-seven" "In-hours" and weekends 10 "In-hours" only Other arrangements 8 7 6 5 5 4 2 0 0 0 Hospitals NetworksNote: On a network level, two networks offer PPCI across multiple hospitalsbut at different times. For example, the PCI centre may offer PPCI 24/7 but areferring DGH may only offer the service ‘in-hours’.Times PPCI providedHIP NIAP Analysis report – V1 5

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• Networks highlighted pink have at least one hospital providing PPCI “24–7” • Networks highlighted turquoise have at least one hospital providing PPCI “in-hours” • Networks highlighted in dark blue have other arrangements or did not state when their service operated. • Networks not shaded as above do not offer PPCIMost hospitals commenced with working in-hours and extended to 24 whenthey developed the expertise and addressed staffing issues. The limitingfactor to providing a 24 hour service is personnel and balancing the out ofhours rota with providing a full service.HIP NIAP Analysis report – V1 6

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Planned changes to current reperfusion servicesNetworks were asked to state any planned changes to either the PHT or PPCIservices offered within the next two years. Those networks that stated theyhad ‘no changed planned’ to their PHT service either provide a full PPCIservice already, or do not have any plans to change their current PHT service.For those networks providing PPCI, work is planned to extend the hours ofPPCI service provision. Planned changes to PHT NetworksNo Changes planned 10Integrate PPCI with PHT service 8Increase number PHT by protocol, support 8Revise protocol - other reasons 6No PHT 3Stream study 1 Planned changes to PPCI services NetworksIn-hours expand area 9In-hours whole network 7No plans 524/7 whole network 3NSTEMIs 324/7 PCI centres 224/7 in limited area 2In-hours PCI centres 2Stream study 2Infrastructure at PCI centre 1Finally, networks were asked to identify any barriers that they feel may needto be overcome in order to develop reperfusion services across their patch. Itwas agreed to follow this up further at a meeting with cardiac networks, andthis formed the basis for discussions at the 04 December meeting (furtherdiscussion below). Barriers to development NetworksWorkforce issues 22Ambulance issues 15Evidence to support PPCI cost effectiveness, funding issues 12Geography 10Who gets paid and for what – tariff unbundling 7Working across organisational boundaries 7Trained paramedics 5No current barriers to overcome, full PPCI service in place 3Capacity of PCI centres 3Clinical evidence of benefit of PPCI 2Development of NSTEMI plans 1Phase 2 – meeting with cardiac networksHIP NIAP Analysis report – V1 7

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The meeting on 04 December focused on further exploring the surveyresponses. Invited to the meeting were cardiac network representatives,members of the NIAP steering group, ambulance service representatives,network clinical leads and NIAP pilot site clinical leads.Discussions at the meeting centred on the current situation regardingreperfusion, future plans, barriers to providing a PPCI service, and anypotential solutions to overcoming these barriers. The main themes of thediscussions focussed around: • Capacity in terms of ambulance availability and cath lab access • Human resource issues • Commissioning • Rural areas with long travelling distances to PPCI centres • Clinical GovernanceCapacity • Ambulance availability • Catheter lab access • Impact on elective workThe availability of ambulances to provide extra journeys and services acrossnetwork boundaries was highlighted as an issue across the country. In orderto provide a full PPCI 24/7 service, an increase in crews and ambulances isneeded, as well as increased communication between ambulance services’ tolook at closer working relationships and tackling the cross boundary issues.An ambulance services strategy was proposed as a potential solution to thisissue, along with networks doing further work to look at the cross boundaryissues and joint working between networks and ambulance services in orderto agree a collective approach to providing a PPCI service.Concerns were raised surrounding the capacity of catheter labs to providePPCI services, particularly out of hours and 24/7. Also, what are theimplications for staff, wards and services at DGH, with increased activity intertiary centres? Some networks stated that they do not believe that theyhave enough cardiologists to provide a full 24/7 PPCI service.A potential solution to this could be to look at moving services to DGH settingsfrom tertiary centres, to alleviate costing/capacity issues of moving servicesout of the DGH with the introduction of PPCI.Human resources • Availability of staff • Hours of work – problems in providing 24/7 • Cardiology rotas • ‘density’ of cardiologists in rural areas • Impact of primary PPCI on DGH CCUThe human resource aspects of providing PPCI are a particular concern for allnetworks. Providing an out of hours or 24/7 service requires a full rota ofmedical and non-medical staff with different skills. The availability of staff toHIP NIAP Analysis report – V1 8

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provide this service based on their current ways of working may not bepossible, and depending on the location of the catheter labs, may not beachievable. Some areas do not have enough interventional cardiologists toinclude on a OOH/24/7 PPCI rota, and, depending on where the PPCI serviceis located, they may not be based at the interventional centre at all times.When asked to identify barriers to change, in relation to workforce issues, onenetwork stated that “(the) need to cover labs overnight adds significantchange to workforce practice”.Another network saw “consultant and other clinical staff working hours and theunwillingness of Trusts in the Network to enable an out-of-hours rota whichcould mean the supplying Trust losing consultant time the following day” as aworkforce barrier to change.A potential solution to the human resource issues are to look at ways ofworking differently, including the introduction of generic catheter lab staff;multi-skillng of professional roles and extending the ‘routine’ working day.Shared rotas and increased joint working between centres may help to reducethe pressure on the human implications of providing a PPCI service.Concerns were raised about the potential deskilling of cardiology staff inDGHs. Consideration should be given to changes to cardiac care units toaccommodate acute coronary syndrome to ensure current skill levels aremaintained. A further potential solution may be to look at the integration ofDGH interventionalists onto PPCI rotas at tertiary centres.Commissioning • Evidence base and cost effectivenessSome commissioners are sceptical about the value of PPCI and its’ costeffectiveness compared to providing thrombolysis for STEMI patients. Theimpact of providing a PPCI service, whether OOH or 24/7, has massivecommissioning implications for staffing levels, capacity levels and ambulanceservices. There is also a concern surrounding the potential commissioningcosts for cardiac rehabilitation unbundling of the tariff.The provision of a reperfusion commissioning guide with keyrecommendations may help to engage commissioners and aid theirunderstanding of providing a PPCI service, along with a clear clinicalreperfusion strategy implemented across the network. Some networksdiscussed the possibility of introducing a ‘repatriation’ tariff as a potentialsolution to the threat to DGH incomes of a PPCI service provided at a tertiarycentre.Geography • Rural areas with long travelling distances • Use of helicoptersProviding a PPCI service across a large geographical patch, particularly inrural areas, is an issue for most cardiac networks. Journey times forambulances to the nearest tertiary centre, and delays in reperfusion due toHIP NIAP Analysis report – V1 9

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geographical spread are highlighted as key concerns to implementing a fullPPCI service.Equity issues surrounding the provision of a PPCI service for those STEMIpatients who live a great distance from a tertiary centre should not beoverlooked.Some networks are discussing the use of PPCI and PHT hybrid approachesas a potential solution to development of their reperfusion strategy. Whilst theuse of helicopters to transfer patients to tertiary centres is being considered inthose areas where long journey times cannot be avoided.Clinical Governance • Evidence base • Cross boundary working • Need for single protocol when have mixed provisionMany networks stated that clinical providers require evidence of the clinicalbenefits of PPCI before they further investigate the provision of a full service.The NIAP report and its’ findings will be able to provide clarity around thisissue.It is clear that, if the evidence base clearly suggests better patient outcomesfor PPCI, that there is a need for clear protocols for the provision of PPCI andany PPCI and PHT hybrid approaches to reperfusion. Such protocols shouldalso cover issues relating to transferring patients across network/geographicalboundaries and the governance issues relating to this.This requires development of clear communication channels between allproviders to ensure that the governance arrangements are clear andunderstood and adhered to by all involved. Rhiannon Pepper & Sheelagh Machin January 2008HIP NIAP Analysis report – V1 10

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APPENDIX ANational Infarct Angioplasty ProjectCardiac network survey of reperfusion strategiesName of network:Name of person completing form:Contact details:Network coverage1. What geographical area does your network cover?2. What is the catchment population?3. How many consultant interventional cardiologists work in your network area? Name of hospital NumberPre-hospital thrombolysis3 Is pre-hospital thrombolysis provided within your network?a (please tick box) Yes, for the whole network Yes, for part of the network No3 Do you have any defined criteria for the use of pre-hospitalb thrombolysis? (please tick box) Yes If yes, please state what they are: NoHIP NIAP Analysis report – V1 11

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Ambulance transfers4 Are there any arrangements for ambulances to transfer STEMIa patients to PPCI centres? (please tick box) No, taken to nearest acute hospital Yes, bypass local hospital to transfer to PPCI centre Yes, assessed at non-PPCI centre then STEMIs transferred to PPCI centre If patients bypass local hospitals, what are the criteria for bypass?4 Do frontline ambulances in the service have 12-lead ECG recording?b (please tick box) All Some Are paramedics trained to interpret the ECG? (please tick box) All Some None Can they send the ECG to the hospital or ambulance centre by telelink of any kind? (please tick box) All Some NoneHospital based reperfusion services5 Within your network, how many hospitals:a Receive patients with STEMI?b Provide thrombolysis for patients with STEMI?c Provide PPCI for patients with STEMI?d Have transfer arrangements to PPCI centre for the majority of STEMIs (bypass or direct transfer from A&E)?e Have transfer arrangements to PPCI centre for occasional STEMIs (on an ad-hoc basis)?f Have transfer only for ‘rescue PCI’?6 For centres providing PPCI (5c above) how many:a Provide a PPCI service - In-hours only? In-hours and weekday nights? 24/7? Other? Please describeHIP NIAP Analysis report – V1 12

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b Have arrangements in place with feeder hospitals to receive: The majority of STEMIs (bypass or direct transfer from A&E) Occasional STEMIs on an ad-hoc basisFuture plans for changes to reperfusion services7 Are there any plans to alter the reperfusion services offered within your network over the next 2 years? If so, please describe:a Any changes to pre-hospital thrombolysisb Any changes to primary angioplasty servicesBarriers to change8 Please describe any barriers that you feel may need to be overcome in order to develop reperfusion services as you would like (i.e., financial, workforce numbers, working practices, physical, services boundaries)Please return your completed survey to Rhiannon.pepper@heart.nhs.uk by 25September 2007.HIP NIAP Analysis report – V1 13